Session 3: Benefit package and the role of health … Observatory on Health Systems and Policies...

European Observatory on Health Systems and Policies

Session 3: Benefit package and the role of health technology assessment (HTA)

Health financing and efficiency gains workshop

Ljubljana, 03 November 2015

Dr. med. Wilm Quentin, MSc HPPF

Senior Research Fellow

Technische Universität Berlin


The purchasing process

(Strategic) purchasing bridges the gap between

planning and budgetary allocations to promote

quality and efficiency in the use of health funds

– Which interventions should be purchased?

– How should these be purchased?

– What payment systems should be used?

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A model for health care benefits

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“All” possible health benefits

Covered benefit categories e.g. “inpatient curative care”, “pre-natal care”

Actually covered benefitse.g. cervical cancer screening with Papanicolau Test;

toxoplasma serology in the first trimester


Listing of benefits: process

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“All” possiblehealth benefits

Covered benefit categories

Actual benefits

Representativeinstitutions, e.g.

Parliaments (Law)

Planning Bodies Coverage Commissions

using HTA

Third-party

Payers

Advisory bodies

(Social) Courts

Criteria


Why is HTA important?

5Kernick 2003

Demand/Need

Intervention options

Resources

1970s 1980s 1990s


Two alternatives for rationing ofbenefits

• Implicit rationing– Officially „no rationing“

– Decisions are made by providers

– Intransparent: effectively certain patients are not treated/certain services not provided (e.g. waiting lists)

• Explicit rationing– Official processes exist to make decisions about which

services to provide

– Improves transparency � allows making trade-offs explicit

– Political costs of negative coverage decisions but may leadto societal debate

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HTA for decision making

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“The goal of HTA is to provide input to decision making in policy and practice“(Henshall et al. 1997)

Industry claims

Providerpreferences

Patientwishes

Societal values

• Therapeutic value• Economic value• Social aspects

• Other aspects (ethical, legal…)


Challenges in Slovenia

• Explicit listing of covered services exists only for few areas, e.g. pharmaceuticals

• No systematic mechanism (based on HTA) that determines whether new services will be covered/existing removed/user charges changed

• No consensus about HTA body (institutional set-up, responsibilities)

• Resistance by stakeholders towards more explicit/evidence-based decision making

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Listing of ALL covered services

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HC.1 Services of curative care

HC.1.1 In-patient curative care HC.1.2 Day cases of curative care HC.1.3 Out-patient care HC.1.3.1 Basic medical and diagnostic services HC.1.3.2 Out-patient dental care HC.1.3.3 All other specialised health care HC.1.3.9 All other out-patient curative care HC.1.4 Services of curative home care HC.2 Services of rehabilitative care

HC.2.1 In-patient rehabilitative care HC.2.2 Day cases of rehabilitative care HC.2.3 Out-patient rehabilitative care HC.2.4 Services of rehabilitative home care HC.3 Services of long-term nursing care

HC.3.1 In-patient long-term nursing care HC.3.2 Day cases of long-term nursing care HC.3.3 Long-term nursing care: home care

HC.4 Ancillary services to health care

HC.4.1 Clinical laboratory HC.4.2 Diagnostic imaging HC.4.3 Patient transport and emergency rescue HC.4.9 All other miscellaneous services HC.5 Medical goods dispensed to out-patients

HC.5.1 Pharmaceuticals and other medical non-durables HC.5.1.1 Prescribed medicines HC.5.1.2 Over-the-counter medicines HC.5.2 Therapeutic appliances and other medical durables HC.5.2.1 Glasses and vision products HC.5.2.2 Orthopaedic appliances and other prosthetics HC.5.2.3 Hearing aids HC.5.2.4 Medico-technical devices, incl. wheelchairs HC.5.2.9 All other miscellaneous medical durables HC.6 Prevention and public health services

HC.6.1 Maternal and child health; family planning … HC.6.2 School health services HC.6.3 Prevention of communicable diseases HC.6.4 Prevention of non-communicable diseases HC.6.5 Occupational health care HC.6.9 All other miscellaneous public health services

OECD System of Health Accounts:

Health Care Functions

To be introduced

by 2017

Losely defined

by DRGs“All” possible health

benefits


Process for listing of benefits in Switzerland (similar in NL)

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HTA used for decision making

SK LV GR PL CZ HR LT RU EE SI BU HU

Pharmaceuticals

(include vaccines and

other biological

products)

X X X X X X X X X X X

Medical devices

(include diagnostic

products)

X X X X X X X

Medical procedures X X X X X

E-health technologies X

Public health

interventionsX X X X

Other X

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Based on survey data, ADVANCE_HTA project, yet unpublished


Criteria for benefit setting differ

across countries and benefits

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Service Categories D DK E F H I NL PL UKCurative Care

In-patient services A; CE; Ex.; N

B; N C; E; N; S

N; E; S

C; E A; N; B C; E; N n.s. B; C; N

Out-patient services CE; Ex.; N

B; N C; E; N; S

N; E; S

C; E A; E; N; B

C; E n.s. C; E; N

Rehabilitative Care CE; Ex.; N

B; N N N n.s. A A n.s. E; N

Long-term nursing care C N N N n.s. A; E; N; B

n.s. n.s. E; N

Ancillary services A; Ex. N C; E; N N n.s. C; E n.s. n.s. E; NMedical goods for out-patients

Pharmaceuticals andnon-durables

E; N B; CE; N

B; N; U C; E; I; S

B; CE; E; N; S

C; E B; CE; I C B; E; N; S

Appliances and durables

E; U U CE; E; S E; U n.s. N; C C N; C E; N; S

a Denmark (DK), France (F) Germany (D), Hungary (H), Italy (I), Netherlands (NL), Poland (PL), Spain (E), England (UK);n.s.: not stated

A: Appropriateness, B: Budget, C: Costs, CE: Cost-effectiveness,E: Effectiveness, Ex.: Expedience, I: Innovation-degree,

N: Need, S: Safety, U: Utility

Velasco-Garrido 2006


HTA: institutional setup and tasks

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Separate

entitiesIntegrated Regulatory

body

HTA institution

Coverage body

TV = Therapeuticvalue

EV = economicvalue

AP = appraisal

Allen 2013


HTA: responsible institutions

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Bulgaria National Council on prices and reimbursement of medicinal products (NCPR) is responsible for assessment, appraisal and reimbursement.

Croatia

Agency for Quality and Accreditation in Health Care and Social Welfare is responsible for assessment. Croatian Institute for Health Insurance (CIHI) (“Drug Committee” and “Medical Devices Committee”) is responsible for appraisal.

Cyprus Drug committee is responsible for assessment, appraisal and decision of reimbursement of medical products.

Czech Repulbic Marketing authorization holder (MAH) is responsible to assessment State Institute of Drug Control (SÙKL) is responsible for appraisal

Estonia

Estonian Heath Insurance Fund is responsible for appraisal. The assessment is based on information submitted by applicant. [no formal process of HTA]

Greece

National Drug Organization (EOF) in collaboration with the National Organisation for the Provision of Healthcare Services of Greece (EOPYY) are responsible for assessment and appraisal process. [no formal process of HTA]

Hungary

Technology Appraisal Head Department (TAHD) in the National Institute for Quality and Organisational Development in Healthcare and medicines (THAD – GYEMSZI TEI-) is responsible for assessment and appraisal.

Kosovo [no formal process of HTA]

Latvia Centre of Health Economics (CHE) within the NHS is responsible for assessment and appraisal

State Health Care Accreditation Agency (VASPVT) perform assessment of medical device.


HTA schemes in five CEE countries

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Gulacsi et al. 2014


HTA prinicples

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Stephens et al. 2012

�� Stakeholder involvement

�� Include all relevant technologies

�� Clearly defined link to policy-making


HTA practices in Europe

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Stephens et al. 2012

v

v


Summary: international experiences

• HTA can be a useful tool to determine which

(new) benefits are to be covered

– Should include all types of services and technologies

– HTA body should be independent of financial interests and not-for-profit

• Selecting topics, evaluation, and decision-

making requires involvement of several actors

– Needs a clear, explicit and regulated definition of roles and responsibilities

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• Clear criteria are needed to guide evaluations

– Internationally, effectiveness, safety and costs (or cost-effectiveness) are most frequently employed

– Collaborate with more experienced countries

• An evidence-based explicit definition of benefits is likely to meet resistance

– If coverage decisions are taken transparently can lead to debate about societal preferences

– Stakeholder involvement is vital to counteract resistance on the provider side

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Slovenia is a

member of

EUnetHTA

Summary: international experiences


Thank you!

For more information:

www.euro.who.int/observatory

www.mig.tu-berlin.de

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Session 3: Benefit package and the role of health … Observatory on Health Systems and Policies...

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